The document describes the process flow for appeals and grievances for a healthcare provider using Newgen's Customer Communication Management solution. The process involves appellants registering appeals/grievances via various channels. A data entry agent then enters the details into Newgen's CCM solution, triggering an auto-generated acknowledgment email. A reviewer makes an approval/exception decision and the committee makes the final call. An approval letter is generated and sent to the appellant if approved.

1. Customer Communication Management Interactive Customer Communication for Appeals & Grievance Process

2. Process Flow for Appeals & Grievances Process for a Healthcare Provider

3. Appellant registers his appeals/ grievances via different channels like email, snail mail, fax, telephonic call etc.. Process Flow for Appeals & Grievances Process for a Healthcare Provider

4. Auto generated acknowledgement mail is sent to the appellant soon after the Data Entry Agent registers the appeal into Newgen’s CCM solution for Interactive Communication Process Flow for Appeals & Grievances Process for a Healthcare Provider

5. The Reviewer takes necessary decision on approval or raising an exception for modifications or even discard the appeal with reasoning and remarks.Process Flow for Appeals & Grievances Process for a Healthcare Provider

6. The committee reviews the Reviewer’s decision and takes the final call on approval of the Appeal. Process Flow for Appeals & Grievances Process for a Healthcare Provider

7. Approval Letter generated over the predefined templates is sent to the appellant and also archived into OmniDocs –DMS , integrated part of Newgen’s CCM SolutionProcess Flow for Appeals & Grievances Process for a Healthcare Provider

8. Data Entry Agent logs-in to the OmniFlow Screen

10. DE Operator initiates a new transaction for every new appeal or grievance entering from different channels.

11. The operator keys in details corresponding to the Appeal on the form created in Newgen's form designer - OmniForm , within the Newgen’s CCM framework

14. The system validates by a popup to check for the confirmation of the decision

15. Auto generated mail is triggered to appellant as an acknowledgement of the receipt and initiation of the A&G process

16. Auto generated html mail from the systemDynamic Data linking of the template to the databases

17. Reviewer logs in the OmniFlow which is the heart of the Newgen’s CCM Solution for Interactive Communication

18. Reviewer logs in the OmniFlow which is the heart of the Newgen’s CCM Solution for Interactive Communication

19. The reviewer selects the corresponding transaction for necessary action execute

20. Reviewer reviews the data entered corresponding to the appeal by the appellant

21. Reviewer reviews the data entered corresponding to the appeal by the appellant

22. Reviewer takes necessary action from the drop down with comments corresponding to it.

23. Reviewer takes necessary action from the drop down with comments corresponding to it.

24. The work item is sent back to the reviewer/ pharmalogical appeal department to make necessary changes for the approval.

25. DE operator / Pharmalogical Appeal Deptt. Operator Logs into the OmniFlow web desktop to make necessary changes in the Appeal

26. DE operator / Pharmalogical Appeal Deptt. Operator Logs into the OmniFlow web desktop to make necessary changes in the Appeal

28. Necessary changes are incorporated by the Pharmalogical Department

29. Validation to confirm the approval from the Reviewer

30. Reviewer’s Log In Screen

31. Reviewer’s Log In Screen

32. Newgen’s Solution framework enables Extensive search capabilities

33. Reviewer again reviews and approves the appeal which is further sent to the committee for further approval

35. Committee Reviewer logs In with the unique Id and password as provided to users at different stages of the approval cycle

36. Committee Reviewer logs In with the unique Id and password as provided to users at different stages of the approval cycle

39. Committee Further reviews the appeal which has been approved by the reviewer and takes necessary action

41. System generates a final statement – approval letter designed in the Composition Designer Module – part of the Newgen’s CCM solution

42. Approval letter documents are archived for reference and compliance measures in the Omni Docs ,integral part of the Newgen’s CCM Solution

43. To view the appeal letters , supervisor logs into the OmniDocs - DMS web interface

44. Documents are maintained into folder and subfolders as per the Business use cases

46. Approval letter corresponding to appeals and the appellant is stored as pdf within the OmniDocs system

47. The case is closed by sending the confirmation e-mail to the appellant on approval

48. Thank YouNewgen Software Technologies Ltd A-6, Satsang Vihar MargQutab Institutional AreaNew Delhi - 110067, IndiaTel: +91-11-26963571Newgen Software Inc1364 Beverly Rd., Ste. 300McLean, VA 22101, USA Tel: +1 (703) 749-2855